Patient's Query
Hello doctor,
I am reaching out to seek a second opinion on my ongoing ear and balance issues, which began following an acoustic trauma I experienced approximately eight months ago. Below is a summary of my condition and treatments to date:
I suffered an acoustic trauma, that resulted in mild hearing loss in my left ear, tinnitus, and a persistent sensation of fullness. After the trauma, I experienced ongoing ear fullness, imbalance, and frequent dizzy spells. While the tinnitus has largely resolved, the other symptoms have persisted.
Physical Therapy: I underwent physical therapy where I was initially treated for BPPV, but the treatment did not fully address my symptoms and may have been misaligned with the underlying cause.
Balance Therapy: Despite some early improvements with balance therapy, about five months after the trauma, my symptoms worsened, particularly the dizzy spells, which were exacerbated by physical activity in hot weather.
Myringotomy: Yesterday, I underwent a myringotomy, in an attempt to relieve the persistent ear fullness and balance issues. Initially, I felt considerable relief, but within 24 hours, the fullness and the instability in my left ear returned, now accompanied by nausea and dizziness.
Current Symptoms: These symptoms remain a significant concern, as they have not improved consistently and, in some cases, have worsened, particularly following certain triggers or activities.
I have included my two early audiograms and my most recent audiogram, along with my vestibular test results for your review. Given the persistence and variability of my symptoms, despite the myringotomy and other treatments, I would greatly appreciate your expert opinion on these findings and any recommendations for further evaluation or treatment. I look forward to your guidance.
Thank you very much for your time and expertise.
Hello,
Welcome to icliniq.com.
I read your query and understand your concern.
First of all, there is no need to panic. You do not have any serious problems, based on my thorough review of your reports.
You had a history of acoustic trauma (hearing loss that happens as a result of a sudden, loud noise, or from ongoing exposure to loud noises), after which, all these symptoms have started. So in peripheral vertigo (a dizzy feeling that stems from a problem with the inner ear), there are a few conditions that have to be ruled out, which include, Menierres disease (a chronic inner ear disorder that leads to recurrent episodes of vertigo, hearing loss and tinnitus), Benign paroxysmal positional vertigo (BPPV), semicircular canal dehiscence (a rare condition where there is an opening in the bone covering the superior semicircular canal of the inner ear), functional or phobic vertigo (dizziness due to some problems in the inner ear).
Since your audiogram is perfect (attachments removed to protect patient identity), and the hearing loss is not episodic, the vertigo is not in the form of attacks Menierres disease is ruled out.
The vestibular tests show no changes with dix hallpike (a test that healthcare providers use to diagnose benign paroxysmal positional vertigo) and other tests are also negative. So BPPV is ruled out. In addition, BPPV does not show fullness of ears and tinnitus (a ringing or buzzing noise in one or both ears) complaints.
In the case of semicircular canal dehiscence, the patient will have giddiness and autophony (they will hear their own heartbeat, footstep sounds, etc.). This is also ruled out in your case.
Functional or phobic vertigo: Your vestibular assessment shows that your anxiety levels are too high. Most probably, what happened maybe, during that acoustic trauma, you would have had mild vestibular neuritis (a self-limiting disease with vestibular symptoms lasting for one to two days, followed by a gradual reduction in symptoms). You had giddiness, but that fear has not left you; a true rotation of the surroundings is not present. Hence, what you are experiencing is not a true vertigo, it could all be a part of anxiety.
There are a few questions that are bothering me
1. Why was a myringotomy (a surgical procedure in which an incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid, or to drain pus from the middle ear) done? Your audiogram and impedance are perfect, and there is no fluid behind your drums. Then why?
2. How is your sleep pattern? Do you get adequate sleep?
3. Have you consulted a therapist before?
4. Was a CT (computed tomography) scan of your temporal bone been done?
Rest assured, my strong opinion based on the symptoms you have explained and the reports, this could be simply anxiety or stress-related which has been misdiagnosed.
I hope that you get your answer.
Please let me know if you want some help.
Thank you.
Patient's Query
Hello doctor,
Thank you for your detailed response, and for reassuring me about my condition. I appreciate your time and expertise in reviewing my reports. I wanted to address a few points and provide some additional context regarding my situation.
1. Myringotomy: The myringotomy was recommended by my current ENT specialist due to persistent eustachian tube dysfunction, particularly in my left ear. I have experienced significant issues with pressure in my left ear, especially after flights, which often exacerbates my balance problems. Despite a normal audiogram, the fullness in my ear and the associated imbalance were significant enough, that my ENT felt this procedure was necessary.
2. Sleep pattern: My sleep has been somewhat irregular, especially with the ongoing symptoms of dizziness and ear fullness. I often find it difficult to fall asleep and stay asleep, particularly during periods when the symptoms are more pronounced.
3. Anxiety and stress: I acknowledge that anxiety could be playing a role in my symptoms. The acoustic trauma and subsequent dizziness have caused a great deal of stress, which might be contributing to the persistence of my symptoms. However, the physical sensations of fullness, unsteadiness, and dizziness have been real and distressing, making it hard to determine where the anxiety ends, and the physical symptoms begin.
5. CT scan: I have not had a CT scan of my temporal bone yet. Given my history and the symptoms, do you think this would be a worthwhile step to rule out any underlying structural issues?
One aspect that I find particularly odd, is the sudden onset of my symptoms after a five-month gap following the initial acoustic trauma. This gap seems unusual to me, and I am concerned about what might have triggered this sudden resurgence of symptoms. While I understand that my symptoms might not fit the classic presentation of conditions like Meniere’s or BPPV, the persistent fullness and occasional unsteadiness, particularly following the myringotomy, continue to concern me. Could this be related to the eustachian tube dysfunction, or should we explore other potential causes? Please advise.
Thank you again.
Hello,
Welcome back to icliniq.com.
Based on the symptoms of ears getting clogged during flights, there could be a slight amount of eustachian tube dysfunction. But people with normal eustachian function also experience these barotrauma (an injury caused by a difference in pressure between the external ear canal and the middle ear) symptoms during flights. That is the reason most of the flights provide you a gummy or chewing gum, so that if you chew them during take-off and landing. The eustachian tube is kept open, and these pressure-related symptoms are taken care of while chewing.
There are alternatives for this, you can do a Valsalva maneuver (performed by a forceful attempt of exhalation against a closed airway), while taking off and landing. You can also use Oxymetazoline or Xylometazoline nasal drops (decongestants) a few minutes before the takeoff and landing, which will enhance eustachian tube function.
I frankly think myringotomy (a surgical procedure in which an incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid, or to drain pus from the middle ear) was overkill with a normal audiogram and impedance. Myringotomy and grommet insertion (a surgical procedure that can be used to relieve pressure or drain fluid from the middle ear) is done usually whenever the patient has chronic glue ear (a condition where the middle ear fills with glue-like fluid instead of air) or retracted tympanic membrane for a long time.
As I had said earlier, all of your symptoms could be just related to anxiety and stress. The fear of harboring some disease itself could lead to a vicious cycle, leading to all these symptoms.
I strongly suggest, before further undergoing any other investigation, please book an appointment with your therapist. Let them assess once. Later, we can always go for further evaluation and investigations.
As a last resort, a CT scan is one investigation that is left out. Sometime later, after your consultation with your therapist, a CT scan be done, but not an emergency.
And coming to your sudden onset of symptoms, it could have also happened that you had a sudden episode of BPPV, after which it has settled on its own. However, the fear of the incident and the anxiety are leading to all your current symptoms.
The giddiness related to eustachian tube dysfunction is the rarest possible cause, we in this part of the world never really believe in this entity itself!
In my opinion, please meet a therapist, get an assessment done, and treatment started. Later, we can always go for further investigation.
I hope that you get your answer.
Please let me know if you want more help.
Thank you.
Patient's Query
Hello doctor,
Thank you for your detailed response.
I wanted to provide some context regarding my eustachian tube dysfunction. After the acoustic trauma, I experienced significant eustachian tube dysfunction and was performing the Valsalva maneuver almost every other minute daily for several months. Given this history, my ENT thought that the myringotomy was a minor procedure that might help alleviate the pressure issues because I kept going to her. She also recommends the nasal decongestant which I do during flights. I fly a lot for my job and actually had to take time off due to how debilitated my balance issues were.
I understand that you believe my imbalance might not be related to eustachian tube dysfunction. However, I have also experienced dizzy spells and balance issues even when I was at home, meditating, and feeling relaxed. Is it 100 percent anxiety-related? What about vestibular therapy? Do you recommend it?
Additionally, the audiologist noted an impression of “left peripheral vestibular (saccule and/or inferior vestibular nerve) dysfunction” following the vestibular testing. Could you possibly clarify if this is reflected in the report graphs I shared with you? I would also hope to understand why I experience dizzy spells after physical exercise I do, like walking and weight lifting.
Thank you for your continued support.
Hello,
Welcome back to icliniq.com.
I suggest getting a nasal spray called Fluticine OX. This is a wonderful combination of two drugs Fluticasone, which reduces inflammation, and Oxymetazoline, which is a decongestant. Use this spray before flights, almost all of my patients are happy with this spray. Consult your doctor and start the medicine accordingly.
As a last resort, the ultimate investigation which will rule out all possibilities should be an MRI (magnetic resonance imaging) brain or CP (Cerebellopontine) angle to rule out any swellings or tumors like acoustic neuroma (non-cancerous tumor on the main nerve leading from the inner ear to the brain).
All though I do not think all these are absolutely necessary, as a last resort, we can get this at some point in time. In the assessment report, I saw there is a little weakness. Sometimes there is a term called vestibulopathy, that is your vestibular apparatus might get a little weak due to some viral infection, which could also cause these symptoms.
But worry not, even if this has happened, our body accommodates on its own. All you might need is vestibular rehabilitation therapy, or vestibular exercises to make your vestibular system adaptive.
I also feel there is a strong association between anxiety and stress in your case. So ideal thing would be to meet a therapist, get anxiety treated, and as well continue the vestibular exercises. You will be perfectly well in a month or two.
I hope that you get your answer.
Please let me know if you want some help.
Thank you.
Patient's Query
Hello doctor,
Thank you so much for your reply.
While this has been very debilitating for me for the past month and a half, your feedback gives me positive reinforcement.
I was recommended Afrin in my place. Will this help?
1. How long should I expect to continue vestibular rehabilitation exercises before noticing significant improvement? I try head exercises how where I look at a target and move my head side to side and up and down.
2. Are there specific exercises you recommend for my case, or should I follow a standard vestibular rehabilitation routine?
3. What signs should I look for that indicate my vestibular system is adapting positively to the exercises?
4. What is the best way to manage a dizzy spell when it happens in public or during activities? Are there any immediate steps I should take to stabilize myself?
5. Should I carry anything specific with me (like certain medications) to help manage dizzy spells when I am outside or traveling?
6. Do I need to modify my exercise routine? Such as removing weight lifting? Until my body learns to compensate.
And yes, I am continuing to focus on my anxiety. It is a journey for me.
Thank you so much in advance!
Hello,
Welcome back to icliniq.com.
It is good that you are working on your anxiety. I would also suggest you to take a professional help, so that you come out of anxiety faster.
Afrin nasal spray (Oxymetazoline) can be used as SOS (in case of emergency). Please do not use it continuously for more than 14 days at a stretch.
For dizziness, there is an SOS mouth-dissolving tablet Prochlorperazine 5 mg, that should help. Consult your doctor and take the medicine accordingly.
Rest assured do not worry. You can get the MRI CP angle also later. Continue vestibular exercise for around two to three months, it will definitely help
I hope that you get your answer.
Please let me know if you want some help.
Thank you.
Patient's Query
Hi doctor,
Thank you so much for your reply. I feel much more assured,
I have a few more questions:
1. Are there specific foods or drinks I should avoid to help manage my dizziness or Eustachian tube dysfunction?
2. Can changes in my diet, like reducing alcohol or caffeine, positively impact my vestibular health? Am I able to enjoy a drink of alcohol every now and then?
3. Should I avoid certain activities (e.g., high-intensity workouts, running, weightlifting) that could trigger dizziness?
Please advise.
Thank you.
Hi,
Welcome back to icliniq.com.
There are no food restrictions related to eustachian tubes or dizziness spells; you can follow your regular diet. You can consume alcohol in moderation, there is absolutely nothing to worry about.
Please do all your routine exercises, do not restrict them. The dictum nowadays is that, rest is bad in giddiness; it delays vestibular compensations.
I hope that you get your answer.
Please let me know if you want more help.
Thank you.
Patient's Query
Hello doctor,
Thank you so much.
I signed up for vestibular therapy in the clinic and did it at home. I attempted light weight lifting exercises and did feel unbalanced, but I trust that my body will learn to compensate. I lost a lot of confidence over the past month and a half. I am trying to get it back.
Any last tips you have are appreciated.
Thank you.
Hi,
Welcome back to icliniq.com.
Please continue with your efforts and do regular exercises. Keep up your positive thoughts. Continue the rehabilitation and keep a positive attitude.
Please let me know if you want more help.
Thank you.
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Answered byDr. Akshay. B. K.
Medically reviewed byiCliniq medical review team
Same symptoms don't mean you have the same problem. Consult a doctor now!
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